Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications
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THERAPY IN PRACTICE
Drug‑Related Orthostatic Hypotension: Beyond Anti‑Hypertensive Medications Giulia Rivasi1 · Martina Rafanelli1 · Enrico Mossello1 · Michele Brignole2 · Andrea Ungar1
© The Author(s) 2020
Abstract Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.
Key Points Several cardiovascular and psychoactive medications may alter the blood pressure response to standing, leading to drug-related orthostatic hypotension. This narrative review provides an overview on cardiovascular and non-cardiovascular medications potentially impairing orthostatic blood pressure. This review may be helpful to guide medical therapy optimization in patients with an abnormal orthostatic blood pressure response, to minimize the risk of drugrelated orthostatic hypotension. * Giulia Rivasi [email protected] 1
Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda OspedalieroUniversitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
2
1 Introduction Orthostatic hypotension (OH) is an impaired blood pressure (BP) response to the upright position which is defined by a systolic BP drop ≥ 20 mmHg or by an absolute systolic BP value ≤ 90 mmHg and/or a diastolic BP drop ≥ 10 mmHg within 3 minutes of standing [1, 2]. It is a recognized risk factor for adverse outcomes such as syncope and falls, cardiovascular events (including coronary events, heart failure hos
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